Noguchi  Ulohtftratinn  of  ttjc 
Waaarrmamt  ©cat  in  fagri|iatrg 

William  H.  Holmes 


Reprinted  from  the  Institution  Quarterly,  Vol.  4,  No.  2 
State  Charities  Commission 
Springfield,  111. 


The  Noguchi  Modification  of  the 
Wassermann  Test  in  Psychiatry. 


By  W.  H.  Holmes,  M.  D.,  Clinical  Pathologist  to  the  Psychopathic  Institute. 

The  technique  of  the  various  sero-diagnostic  tests  is  a subject 
which  has  received  its  full  share  of  attention  in  the  literature.  For 
that  reason  no  description  of  the  technique  followed  in  this  labora- 
tory will  be  given.  The  tests  are  made  according  to  Noguchi’s 
modification  of  the  original  Wassermann  method.  The  antigen  used 
is  an  alcoholic  extract  of  a syphilitic  foetal  liver,  prepared  and  kindly 
furnished  by  Dr.  W.  H.  Buhlig  of  Chicago. 

The  object  of  this  paper  is  to  record  the  results  obtained  in  this 
laboratory  in  cases  of : 

(1)  Typical  General  Paralysis. 

(2)  Typical  Tabes  Dorsalis. 

(3)  Typical  Cerebro-spinal  Syphilis. 

(4)  Atypical  cases  of  General  Paralysis  in  which  the  test  proved  of  value 
in  arriving  at  a correct  diagnosis. 

(5)  Miscellaneous  cases. 

Notwithstanding  the  fact  that  there  has  been  an  immense  amount 
of  work  done  in  neurological  serology,  the  exact  value  of  the  pro- 
„ ^ce^.ure  is,  in  the  minds  of  many,  still  somewhat  in  doubt.  For  that 
reason  I have  deemed  it  advisable  to  make  a statistical  study  of  the 
- available  literature.  The  review  is  confined  to  three  diseases,  viz., 
paresis,  tabes  and  cerebro-spinal  syphilis.  Doubtless  many  cases 
have  been  overlooked.  A number  have  been  purposely  omitted  be- 
cause I did  not  feel  satisfied  that  they  were  typical  cases.  Other 
cases  are  omitted  because  it  was  not  definitely  stated  whether  the 

v blood  serum  or  spinal  fluid  was  examined. 

. 

(_fi  From  Table  I it  is  readily  seen  that  relatively  few  authors  confirm  the 
belief  of  Plaut,i  who  states  “The  serum  in  paresis  always  reacts  positively.” 
Yet  the  average  percentage  in  which  the  serum  is  positive  is  so  high  (90%) 
that  one  is  justified  in  stating  that  a negative  reaction  of  the  serum  makes  a 
diagnosis  of  general  paralysis  highly  doubtful. 

Referring  again  to  Plaut’s  work,  we  find  that  he  believes  a negative  spinal 
fluid  and  a positive  serum  in  a case  of  organic  brain  disease  is  more  likely 


Table  I — General  Paralysis. 


•aAtirsod 
}uab  .lad 


•inj^qnop 

PUB  9At}BS9JN 


oioteooo^ 


C-ips  •C'-Ol  -00 


> <M  • o cn  -in  eoooooi 


•9Ai;iSOd[ 


•S9SB0 

JO  -ok 


OOOOOH  O NO 


•9AI^ISOd 

}U9o  jgj 


•inj;qnop 

PUB  9AI}BS9]^ 

1 


OOONN O 


•gAIJISOtJ 


iOON  U3  O 


<Oil>I>lOOCOO(MO 


OOtNlMCOOOOi 


<X>OCO  * LO  ' 


WO0C  '(MW 


•SaS'BD 

JO  'ON 


•poqj9M 


UB9A 


OHHt>OJl>OOO^a5aiOOOOHOOOOHOOai05HH  •t>OOO^C5 
rHrHfHOOOOOOOOOrHT-HOrHrHOOOTHTH  -OOOO 

O^O^CJiCJSO^O^O^O^O^CSC^CJiO^C^O^O^CJiO^CJiO^O^O^  • <J^  Ci  <J5  C5 


O H O 00  00  H 
rHrHrHOOi-* 

<J*  Ci  Ci  05  Ci 


•jgqumjsi 


(Moscqoo  ^C'-ooccoq-'C'axMeooqcocoT 
CM  . coco  cq 

eg  eg  £ eg  ^ 


HLOCD 
COCO 
<M  CSJ 


OOOO 

»» 


^ AA  W A-,  ' 04h  (-5 

^ o£s.  ° • 
.P  .fc> 


P'W 
Ph  3- 


NvNS^SS  • N. 


o 


2 o . o 

*2*^3^ 


, •+_>  . TO  ri+J  ' ,•  . ra 


3 w 1 

c$  cj 

,Q  W . 


lO^O 


w . CH'  u 

-r<  ^ o >» 
t/2  ft  VI  *rH  O-rt 

So  0^5 'w4j 


P h p'l^  H P"H  S d PSrrt  d1;!  a d Cjf3  3ri!  O 5 ^PrtlR 
<D  (U  ® O A ® ®t3  1)  ® « • O O ^ • O • 3 C . .•  . 

PPQQM^QWSoQn  -G<0  ■ ■ 


o o 


a3  . • • d 

^ s' ft  o om 
OCCN^ 
g'O'-s 

05  OJ  5ft  .AH  Q 

02GQ<jO<Ji-5 


005  (M  CO 


<MLO  LO  ^ 


w -oo  o 


iO  ‘OCO 


0050505  I 
rHOOO  I 
05  05  05  05  | 


iih 
0)  • 

,c  ^.d  g 

U3U§ 


><E 


=3 


>-» 

»'g~ 

s®: 

d -i 


43 
o 
3 
be 
c o 

&z 

t* 

c3  •- 

”o 
®43 
S3  CD 

is 

«g 


S3  M 

•r-.  m 

43  ci 


0)  _ 


to  be  cerebro-spinal  syphilis  than  paresis.  Directly  opposed  to  this  are 
the  findings  of  Marie,  Levaditi,  and  Yamanouchi,  who  give  statistics  of 
ninety  cases  of  paresis  which  they  classify  as  follows: 


Cerebro-spinal  fluid. 

Bloom  serum. 

Posi- 

Nega- Not  ex- 

Posi- 

Nega- Not  ex- 

tive. 

tive.  amined. 

tive. 

tive.  amined. 

Incipient  stage,  25  cases 

19 

6 

14 

11 

Fully  dev.  stage,  25  cases. . . . 

8 

17 

20 

5 , . . 

Late  stage,  40  cases 

3 

20  17 

34 

4 

They  maintain  that  the  reaction  is  more  likely  to  be 

positive  in  the  spinal 

fluid  in  the  late  stages  of  the  disease  but  that  as  the  disease  progresses,  the 
serum  is  less  likely  to  be  positive. 


As  will  be  seen,  my  own  results  would  lead  me  to  believe  that  Plaut’s  dic- 
tum is  more  nearly  correct  than  are  those  of  his  critics. 

There  are  two  sources  of  error  which  should  receive  careful  consideration 
by  those  who  obtain  results  diametrically  opposite  to  those  of  other  reliable 
workers.  One  is  the  possibility  of  technical  errors;  the  other  the  possi- 
bility of  an  incorrect  clinical  diagnosis. 

Early  in  my  work  I was  confronted  with  this  question,  “Are  those  cases 
which  give  a negative  serum  reaction,  true  cases  of  general  paralysis?” 
Manifestly  in  many  cases  it  can  be  answered  only  by  autopsy  and  micros- 
copical examination  of  the  brain.  In  other  cases  the  subsequent  course  of 
the  disease  may  show  where  we  have  been  led  astray.  A case  giving  a nega- 
tive reaction  in  the  spinal  fluid  was,  in  the  opinion  of  every  member  of  the 
staff  of  the  hospital  in  which  he  was  confined,  a true  case  of  general  paraly- 
sis. In  the  course  of  time,  he  developed  the  following  symptoms:  marked 
nystagmus,  scanning  speech,  intention  tremor,  cerebellar  gait,  spasticity, 
etc.  The  pupils  were  very  small  and  diminished  in  activity  to  both  light 
and  accommodation.  The  above  findings  make  the  diagnosis  of  general 
paralysis  very  doubtful,  and  the  presence  of  some  other  organic  nervous  dis- 
ease more  probable.  Another  case  was  later  classified  as  belonging  to  the 
Infective-Exhaustive  group.  Two  others,  in  which  the  spinal  fluid  only  was 
sent  for  examination,  were  classified  as  cerebro-spinal  syphilis.  The  above 
cases  are  sufficient  to  show  the  extreme  care  necessary  in  making  a clinical 
examination  of  patients  before  drawing  conclusions  as  to  the  value  of  a 
serologic  test. 

Among  technical  errors,  I believe  one  of  the  most  important  is  bacterial 
contamination  of  the  specimens.  Both  sera  and  spinal  fluids  from  known 
cases  of  general  paralysis,  sent  to  us  by  one  hospital,  invariably  gave  nega- 
tive reactions.  We  were  at  a loss  to  account  for  this  fact,  since  specimens 
from  other  hospitals  were  giving  uniformly  satisfactory  results.  A micro- 
scopical examination  of  the  specimens  showed  that  some  were  grossly  con- 
taminated by  large  sporulating  bacilli  resembling  the  B.  subtilis.  Some 
contained  actively  motile  bacilli,  and  still  others  cocci  of  various  kinds.  For 
this  reason,  no  cases  of  any  kind  from  this  hospital  are  included  in  our 
statistics,  although,  after  the  attention  of  the  hospital  staff  was  called  to  the 
contaminations,  the  results  were  much  better. 

The  61  cases  examined  by  me  represent  all  stages  of  the  malady.  I could 
see  no  relationship  of  the  intensity  of  the  reaction  in  the  serum  or  spinal 
fluid  to  the  stage  of  the  disease.  The  two  fluids,  in  the  majority  of  cases, 
reacted  with  almost  equal  intensity.  In  a few  cases,  the  serum  showed  a 
more  complete  inhibition  of  hemolysis. 

The  physical  and  mental  signs  and  symptoms  in  these  cases  makes  the 
diagnosis  of  general  paralysis  almost  certain. 


Positive. 

Negative.  Doubtful. 

30 

0 

0 

10 

0 

0 

20 

0 

1 

In  30  cases,  blood  serum  only 
In  10  cases,  spinal  fluid  only... 
In  21  cases,  both  fluids 


5 


Of  51  speciments  of  blood  serum  the  reaction  was  therefore  positive  in  98 
Der  cent  and  of  31  specimens  of  spinal  fluid  it  was  positive  in  96.7  per  cent. 

The  single  case,  in  which  the  reaction  was  doubtful  in  both  fluids,  gave 
strongly  positive  findings  otherwise.  The  ammonium  sulphate  and  butyric 
acid  tests  were  both  positive  and  a cell  count  (Fuchs-Rosenthal  method) 
showed  100  cells  to  the  cubic  millimeter.  All  'the  other  fluids  also  gave 
positive  cell  counts  and  positive  globulin  tests. 


TABES. 

Five  cases  of  typical  tabes  in  which  the  blood  was  examined  gave  2 posi- 
tive results.  One  of  the  positive  cases  gave  a negative  reaction  when  re- 
examined after  a lapse  of  six  months.  No  anti-syphilitic  treatment  had 
been  given. 

From  the  following  table  it  will  be  seen  that  the  majqrity  of  Tabetics  are 
syphilitic  and  that  the  blood  serum  reacts  positively  much  more  frequently 
than  does  the  spinal  fluid: 

Table  II — Tabes  Dorsalis. 


Name. 

Bloom 

serum. 

Cer.  spinal  fluid. 

No.  of 
cases. 

Positive. 

Doubtful  or 
negative. 

Per  cent 
positive. 

No.  of  ■ 
cases. 

Positive. 

Doubtful  or 

negative. 

Per  cent 

positive. 

Assmann  •. 

11 

6 

5 

54.5 

3 

2 

1 

66.6 

Beltz  

4 

2 

2 

50 

4 

1 

3 

25 

Citron  

15 

12 

3 

80 

9 

2 

7 

22 

Eichelberg  u.  Pfortner 

7 

6 

1 

85 

7 

5 

2 

71 

Edel  . . 

7 

5 

2 

71 

Eichelberg  

49 

27 

22 

55 

Fraenkel-Heiden  . 

3 

1 

2 

33 

Hough 

1 

1 

100 

Klineberger  

17 

17 

100 

18 

9 

9 

50 

Kaplan  

306 

161 

145 

52.5 

Lesser  

61 

34 

27 

55.7 

Lederma.n  

41 

31 

10 

75 

Noguchi  - 

125 

85 

40 

68 

Noguchi  & Moore 

11 

6 

5 

54.5 

Schutze  (1) '. . 

78 

51 

27 

65 

29 

23 

6 

79 

Nonne  Plolzmann  (2) 

92 

62 

30 

67 

92 

8 

84 

9 

Plaut  

14 

11 

3 

78 

11 

7 

4 

63 

Stertz  

5 

3 

2 

60 

Zaloziecki  

4 

4 

100 

1 

1 

100 

Wassermeyer  & Bering 

7 

4 

3 

56 

3 

1 

' ’ '2 

33 

Williamson  

5 

4 

1 

80 

Total 

793 

493 

300 

62 

247 

99 

• 148 

40 

(1)  Zeit.  f.  klin.  Med.  65  Nos.  5 and  6;  Berl.  klin.  Woch  No.  5,  1907. 

(2)  Monat.  f.  Psych,  u.  Nerv.  Vol.  28,  No.  2,  1910. 


CEREBRO-SPINAL  SYPHILIS. 

Three  cases  of  cerebro-spinal  syphilis  in  which  the  spinal  fluid  only  was 
examined  gave  negative  reactions.  There  was  an  increase  globulin  con- 
tent in  all.  Of  4 cases  in  which  the  blood  only  was  examined  3 were  posi- 
tive and  1 was  negative.  The  case  giving  a negative  reaction  had  been  in 
the  Kankakee  State  Hospital  nearly,a  year  and  had  been  thoroughly  treated. 
The  small  number  of  cases  of  cerebro-spinal  syphilis  examined  by  me  does 
not  permit  the  drawing  of  conclusions,  but  a study  of  the  following 
statistics  cannot  fail  to  convince  one  that  the  spinal  fluid  is  much  more 


6 


likely  to  give  a negative  reaction  than  a positive  one.  This  fact,  of  little 
value  by  itself,  is  in  my  opinion  significant  when  associated  with  a positive 
cell  count  and  an  increased  globulin  content. 

Table  III — CerebroSpinal  Syphilis. 


Name. 

Blood 

serum. 

Cer.  spinal  fluid. 

No.  of 

cases. 

Positive. 

Doubtful  or 

negative. 

Per  cent 

positive. 

No.  of 

• cases. 

Positive. 

Doubtful  or 

negative.  • 

Per  cent 

j positive. 

Assmann  

10 

9 

1 

90 

8 

4 

4 

50 

Eichelberg  & Pfortner 

7 

7 

100 

7 

1 

6 

14 

Hough  

7 

7 

100 

Kafka  

2 

1 

. . ... 

50 

6 

1 

5 

16 

Klineberger  

27 

20 

7 

74 

29 

7 

22 

24 

Ledermann  

11 

11 

100 

Rosanoff  & Wisemann 

1 

1 

. . 

100 

1 

1 

100 

Stertz  

' 3 

2 

66 

8 

’ ’ *8 

Wassermeyer  & Bering 

7 

6 

1 

85 

5 

*"i 

4 

20 

Williamson  

3 

3 

100 

Zaloziecki  

4 

2 

2 

50 

1 

. . 

Beltz  

12 

8 

4 

66 

12 

”7 

5 

58 

Plaut  

20 

19 

1 

95 

20 

3 

17 

15 

Foerster  

5 

2 

3 

40 

Fraenkel-Heiden  

7 

2 

. 5 

28 

Marie,  Levaditi  & Yamanouchi. . . . 

6 

1 

5 

16 

Schutze  

4 

4 

Noguchi  

5 

3 

2 

60 

Noguchi  & Moore 

6 

3 

3 

50 

Eichelberg  

.18 

7 

11 

39 

Total 

123 

98 

25 

80 

139 

41 

98 

29 

In  the  followng  table  IV  are  reported  a small  group  of  cases  in  which 
the  psychoses  are  of  non-luetic  origin.  As  with  cerebro-spinal  syphilis  the 
material  is  too  limited  to  draw  conclusions,  but  the  findings  in  Dementia 
Praecox  and  Manic  Depressive  insanity  are  in  accord  with  those  of  other 
workers: 


Table  IV. 


Blood 

serum. 

Cer.  spinal  fluid. 

Positive. 

Negative 

Positive. 

Negative. 

Cerebral  thrombosis 

0 

2 

Cerebral  hemorrhage.  . 

0 

2 

Arteriosclerosis  

0 

9 

0 

3 

Multiple  sclerosis . 

0 

1 

Huntington’s  Chorea 

0 

2 

Infective  exhaustive  psychoses 

0 

• 6 

0 

1 

Alcoholism  

0 

3 

0 

1 

Pellagra  

0 

2 

Dementia  praecox... 

2 

8 

Manic  depressive  insanitv 

1 

3 

Paranoic  State 

0 

2 

Idiocy  

1 

0 

Mental  defective 

0 

1 

Epilepsy  

0 

1 

Epilepsv  with  Secondarv  svphilis 

1 

0 

Unclassified  

3 

8 

0 

1 

Totals 

8 

49 

0 

8 

7 


There  remains  then  for  further  study  a small  group  of  cases,  which  at 
first  were  wrongly  diagnosed,  and  in  which  the  Wassermann  test  led  to  a 
revised  and  correct  classification. 

Case  1.  I.  M.  G.  examined  by  Dr.  S.  N.  Clark  of  the  Kankakee  State  Hos- 
pital to  whom  I am  indebted  for  the  following  account:  Admitted  April  28, 
1911,  age  38.  No  previous  attacks.  The  history  was  obtained  from  her  hus- 
band: Patient  first  showed  signs  of  mental  derangement  in  December, 
1910.  She  was  very  nervous,  excited  and  continually  talking  to  herself. 
She  suffered  from  very  severe  headaches  which  caused  her  to  go  from  one 
physician  to  another  seeking  relief.  Later  she  took  up  Christian  Science, 
New  Thought  and  other  similar  cults,  but  without  any  relief.  In  January, 
a physician  examined  hejr,  and  made  a diagnosis  of  salpingitis.  He  sent 
her  to  hospital  for  operation  and  stated  that  this  would  result  in  recovery. 
In  the  hospital  she  was  very  noisy  and  they  refused  to  allow  her  to  stay. 
Since  then  she  has  gradually  grown  worse,  becoming  more  and  more  irri- 
table and  noisy,  and  has  developed  delusions?  believing  that  her  husband’s 
employer  was  going  to  kill  him.  Within  the  last  few  weeks  before  admis- 
sion she  has  come  to  believe  that  they  are  also  going  to  kill  her.  The 
husband  stated  that  for  three  days  out  of  a week  she  would  be  apparently 
perfectly  normal,  working  about  the  house  as  usual,  whereas  during  the 
balance  of  the  time  she  would  undo  everything  that  she  had  done.  During 
the  month  of  January  she  constantly  lost  in  flesh.  Her  normal  weight  is 
125  pounds,  on  admission  it  was  98  pounds.  She  has  always  recognized  her 
husband  and  has  been  oriented  for  time  and  place.  The  husband  stated  that 
there  have  been  no  attacks  during  the  seven  years  that  he  has  known  her, 
and  he  does  not  know  of  any  previous  to  that  time.  Physically  the  patient 
was  rather  poorly  developed  and  poorly  nourished,  muscles  fairly  firm. 
Mucous  membranes  were  palb.  Conjunctivse  slightly  icteric.  No  rough- 
ness of  the  tibial  crests  or  other  suggestion  of  luetic  infection.  Discolored 
spot  on  left  lower  shin.  Apparent  age  36.  There  was  some  cough  and  a few 
dry  rales  were  to  be  heard  at  the  left  apex.  Urine  examination  revealed  a 
trace  of  albumen  with  many  pus  cells  but  was  otherwise  negative.  The 
second  aortic  sound  was  accentuated  but  the  pulse  small,  easily  compress- 
ible, regular  and  80  per  minute.  Slight  hardening  was  perceptible  in  the 
palpable  arteries.  Digestive  system  negative.  In  the  nervous  syste,m  special 
senses  and  cutaneous  sensibility  were  normal.  There  was  no  abnormal  de- 
gree of  tenderness  on  pressure  over  nerve  trunks  or  muscles.  Sense  of 
position  and  passive  motion  normal.  Occasionally  there  seemed  to  be  slight 
difficulty  in  approximating  the  fingers  with  the  eyes  closed.  Finger-nose 
test  well  done.  Slight  difficulty  in  walking  a straight  line.  Pupils  were 
2 mm.  in  diameter,  equal,  regular  in  outline,  centrally  placed  and-  reacted 
well  to  light  and  accommodation.  Consensual  reaction  normal.  Palpebral 
fissures  equal  and  wider  than  normal.  No  nystagmus.  There  seemed  to  be 
a slight  asymmetry  in  the  facial  muscles.  Tongue  protruded  in  the  median 
line.  Voice  somewhat  hoarse.  No  defect  in  articulation.  The  two  sides  of 
the  body  symmetrically  developed.  Dynamometer  registered  102  in  the 
right  hand,  67  in  the  left.  Slight  tremor  of  fingers.  Superficial  reflexes 
normal.  Deep  reflexes,  excepting  the  knee  jerks  which  were  normal,  were 
exaggerated  but  equal  on  the  two  sides.  No  Babinski  or  Gordon’s  reflexes. 
No  disturbance  of  organic  reflexes. 

Mentally  the  patient  seemed  to  be  clear  and  was  correctly  oriented  for 
time,  place  and  person  but  she  did  not  very  fully  grasp  the  whole  meaning 
of  the  situation.  She  talked  freely,  showing  some  disjtractibility  by  events 
in  her  surroundings  together  with  marked  circumstantialty.  She  con- 
tinued talking  even  when  alone.  At  times  she  appeared  slightly  euphoric 
and  showed  considerable  irritability.  When  questioned,  she  stated  she  felt 
sad  because  she  was  away  from  home,  but  otherwise  well.  She  expressed  a 
definite  delusional  trend  with  regard  to  persecutions,  ill-systematised,  to 
which  she  did  not  very  adequately  adjust  herself,  and  also  spoke  somewhat 
* vaguely  of  visual  and  auditory  hallucinations.  No  defects  in  memory  or 
impressibility  were  definitely  determined  but  she  was  unable  to  give  a 
resume  of  a story  read  to  her.  This  was  thought  to  be  the  result  of  dis- 


8 


tracted  attention  and  she  was  regarded  as  a case  of  manic  depressive  in- 
sanity. 

When  her  husband  was  interviewed  by  the  writer,  as  the  result  of  the 
intervention  of  a mutual  friend,  it  was  noticed  that  his  left  pupil  was  con- 
siderably larger  than  the  right,  there  was  a slight  tremor  of  the  lips,  some 
speech  defect,  the  right  side  of  the  mouth  opened  more  widely  than  the 
left,  and  the  right  naso-labial  fold  was  deeper  than  the  left.  Consequently 
a serologic  examination  was  made  upon  his  wife  with  the  following  results: 

Wassermann  blood  examination  positive  (4  plus).  Spinal  fluid  examina- 
tion was  made  November  7th.  Noguchi  butyric  acid  test  positive.  Nonne- 
Apelt  test  positive.  No  reduction  with  Fehling’s  solution.  Cell  count:  50 
cells  per  cubic  millimeter.  9 

The  further  course  of  the  case  has  left  no  room  for  doubt  as  to  the  nature 
of  the  disease. 

Case  2.  S.  C.,  age  28.  History  of  loose  and  immoral  life.  Abrupt  onset 
August  20,  when  she  became  nervous  and  was  unconscious  for  15  minutes. 
Physical  examination  on  admission  was  absolutely  negative.  Mentally  she 
was  clear  and  well  oriented.  Showed  a smiling,  contented  attitude  with 
elevated  mood  but  no  marked  press  of  activity.  Her  mental  stream  gave 
evidence  of  marked  distractibility  with  numerous  sound  associations.  She 
ivas  clean  and  tidy  in  her  habits,  but  somewhat  careless  of  personal  ex- 
posure. No  delusions  or  sense  falsifications  were  discovered.  Her  memory 
was  apparently  good  and  no  discrepencies  in  her  story  were  detected.  Im- 
pressibility was  faulty  but  this  was  ascribed  to  distractibility. 

Following  this  there  was  a period  of  dull  depression  with  lack  of  energy 
which  was  soon  followed  by  rapid  physical  failure  with  fainting  spells  and 
epileptiform  seizures.  The  diagnosis  originally  made  was  that  of  manic- 
depressive  insanity  but  the  absence  of  any  marked  activity  and  the  con- 
tented character  of  the  mood  suggested  an  inadequacy,  with  the  consequence 
that  laboratory  tests  were  made  with  the  following  results: 

Noguchi  butyric  acid,  Nonne-Apelt  and  reduction  tests  on  the  cerebro- 
spinal fluid  all  positive.  Cell  count,  112  per  cub.  mm.  Noguchi-Wassermann 
test  positive  on  blood  serum  and  cerebro-spinal  fluid  (4  plus  in  both). 

Other  cases  might  be  cited  to  illustrate  the  value  of  the  serum  test  in 
diagnosis  in  doubtful  cases  but  these  will  suffice. 


Conclusions. 

1.  The  Noguchi  modification  of  the  Wassermann  test  gives  very  useful 
and  reliable  results  in  the  diagnosis  of  syphilitic  and  parasyphilitic  disease 
of  the  nervous  system. 

2.  In  general  paralysis  of  the  insane  a negative  reaction  in  the  blood 
serum  is  very  exceptional. (98  per  cent  positive  in  the  cases  here  reported 
and  90  per  cent  positive  in  1,198  cases  from  the  literature.)  In  the  cerebro- 
spinal fluid  a positive  reaction  occurs  in  nearly  the  same  numbers.  (96.7 
per  cent  in  our  cases  and  81  per  cent  in  1,076  cases  in  the  literature.) 

3.  A negative  reaction  in  the  cerebro-spinal  fluid  with  a positive  in  the 
blood  serum  occurs  more  frequently  in  cerebro-spinal  syphilis  than  in 
general  paralysis.  (123  cases  in  the  literature  give  80  per  cent  positive  in 
the  blood  serum,  while  139  cases  give  only  29  per  cent  positive  in  the 
cerebro-spinal  fluid.) 


/ 


.UNIVERSITY  OF  ILLINOIS -URBANA 


N301 12088567901A 


